Puberty and menstruation knowledge among young adolescents in low- and middle-income countries: a scoping review

Knowledge of puberty

Few (9/44) studies address knowledge of puberty, and none include early sexual feelings, sexual development, sexuality, or related topics. These findings may reflect an elision by researchers and/or respondents of puberty with menstruation for girls. However, puberty is a broad set of changes, of which menstruation is one. One study, from Turkey, provided unambiguous definition of what the authors defined as “normal” puberty development (Isguven et al. 2015). In this survey of schoolgirls, three quarters (75.2%) self-identified as being knowledgeable about puberty and answered detailed questions about the first symptom of puberty (breast development, pubic and axillary hair, acne).

A study from Nigeria reported attitudes of mothers towards teaching their daughters about a variety of sexual and reproductive health issues. Most mothers (88.6%) agreed that adolescent girls should be informed about body changed at puberty (Iliyasu et al. 2012). In mothers’ narratives about discussions with their daughters, issues of puberty were bound up with issues relating to appearance, dress, use of cosmetics, courtship, sexuality and sexual behaviour. A comparative study of Nigeria and Kenya found that female adolescents were more likely to mention breast development than menstruation as associated with puberty. Adolescents went to great lengths to try to hide their bodily changes from others, including parents (Bello et al. 2017).

An Iranian study evaluated an educational program about puberty health on schoolgirls’ knowledge (Moodi et al. 2013). The study reported a significant difference between pre- and post-intervention results (p < 0.001), although there is little detail about either the intervention content or how knowledge scores were developed. The authors noted that due to shame and modesty, pre-pubertal girls tended not to discuss puberty with their mother. Though multiple studies from Iran focused on “puberty health” in their aims, the content frequently reported girls’ knowledge and experience of menstruation (Afsari et al. 2017a; Kheirollahi et al. 2017; Saghi et al. 2016; Valizadeh et al. 2017). This implies a potential elision by researchers of puberty with menstruation.

Knowledge of menstruation

Knowledge of menstruation was a frequently included outcome (25/44). Across studies, girls have inadequate knowledge about menstruation and low levels of knowledge pre-menarche. A study from Bangladesh reported that 64% of girls were “reaching menarche in fear” (Bosch et al. 2008). In India, 60.3% girls did not know about menstruation prior to menarche, and they reported a poor understanding of the source and pathway of menstrual blood (Shah et al. 2013). Menarche as a trigger for girls learning about menstruation was common (Iliyasu et al. 2012; Mason et al. 2013).

Some studies framed questions in terms of “normal” age at menarche, "normal" duration of menstrual cycle, or "normal" flow. With one exception (Isguven et al. 2015), however, it is unclear how researchers define “normal”. Some studies did not report whether the response categories in surveys were closed or open ended (with post hoc coding). In Nepal, responses to the question “what is menstruation?” were reported using three categories (physiological, pathological, curse); it is unclear whether these were closed response categories, and if they were, how respondents understood the meanings (Adhikari et al. 2007).

Whilst most studies used survey questions, a study from India conducted a content analysis of questions about menstruation posed by girls aged 9–13 years, such as “Do we become infertile if our sanitary pad that is left in open is eaten or sniffed by a snake?” (Chothe et al. 2014). These questions provided culturally and contextually relevant insights into young adolescents’ understandings of menstruation. However, teachers were present during these question-and-answer sessions, potentially influencing girls’ questions.

Three studies examined interventions addressing knowledge of menstruation, all using a pre–post-test design (Haque et al. 2014; Shah et al. 2013; Sharma et al. 2015). An intervention in Bangladesh involved training schoolgirls on menstrual hygiene and reported significant (p < 0.001) impacts on some aspects of knowledge (e.g. menstruation blood is impure) but not others (e.g. cause of menstruation, origin of menstrual blood). This intervention study reported that recruiting female research assistants helped participants feel more comfortable discussing menstruation (Haque et al. 2014). Levels of knowledge about the biological (as opposed to hygiene) content of the intervention were not significantly improved. The authors posed a questionnaire during group discussions, raising issues about priming effects.

Attitudes, myths, and/or perceptions about menstruation

Sixteen studies addressed fear, shame, secrecy, sexual vulnerability, positive/negative attitudes, and sociocultural constraints rooted in myths and taboos. Kenyan girls perceived pubescent, menstruating girls to be increasingly vulnerable to marriage, sexual advances, and abuse (Mason et al. 2013). A study in Bangladesh reported that 17% of girls asked questions about menstruation that researchers classified as myths and taboos (Bosch et al. 2008). Comparative analysis from India showed higher negative attitudes towards menarche in rural compared to urban areas (Anbumalar and Sasirekha 2016). A phenomenological analysis from Jordan found that adolescent girls considered talking about menarche to be “socially unacceptable” and “rude” (Al Omari et al. 2016).

Two studies measured girls’ attitudes towards menstruation in Bangladesh and Mexico. Upon reaching menarche in Bangladesh, nearly two-thirds (64%) of girls reported feeling scared (Bosch et al. 2008). Mexican schoolgirls were significantly (p < 0.0001) more likely to have negative feelings or feelings of secrecy about menstruation than they were to have positive feelings. Girls who were more knowledgeable and felt prepared for menstruation felt less negative and secretive (Marván and Molina-Abolnik 2012). A software intervention in China reported a statistically significant decrease in attitudes that menstruation was “debilitating and bothersome” in the group that received an educational intervention (Su and Lindell 2016).

Sources of information about menstruation/puberty

Most studies revealed that girls obtained information about menstruation and/or puberty from their mothers. Mothers, however, were not necessarily girls’ preferred source of information. Some studies asked adolescents whom they thought should be teaching them. In Nepal, most girls (65.3%) preferred learning from a course book (Adhikari et al. 2007). In Turkey, when schoolgirls were asked who should provide education about puberty, the majority reported health professionals (54.4%) compared to families (30.0%) or teachers (5.9%) (2013). Whilst girls most often received information from females (e.g. mothers, sisters, friends, and female teachers), a few reported receiving information about menstruation and/or puberty from males (e.g. fathers, uncles, male teachers) (Isguven et al. 2015; Mason et al. 2013).

In some studies, it was unclear on what basis adolescents made judgements about the quality of menstruation information. A study from Nepal that asked schoolgirls whether they felt that they had been properly taught about menstruation reported that 98.0% of girls felt that they were not properly taught; it is unclear how “properly” was defined by the researchers or understood by the respondents (Adhikari et al. 2007).

Experiences of menstruation or puberty

The majority of studies (26/44) included at least one outcome measure related to experience of menstruation; experience of puberty was rarely studied (1/44). Dependent upon the sociocultural context, some surveys asked questions about what girls can and cannot do whilst menstruating. A study from Nepal found that 70.7% of girls reported that girls cannot go to school and that 100% reported that girls cannot cook whilst menstruating (Adhikari et al. 2007).

Affective aspects of menarche and menstruation were reported. A study from Mexico that grouped girls by age at menarche found significant differences in the reporting of emotional responses to menarche. Compared to early maturers, late maturers were significantly less likely to report being scared, sad, and worried about menarche, and significantly more likely to report being excited or happy (Marván and Alcalá-Herrera 2014). Late maturers were significantly less likely to report that they would have to keep their first period a secret. The authors describe earlier maturers as experiencing a “truncated preparation time to develop the resources and skills needed to cope [with menarche]” (Marván and Alcalá-Herrera 2014).

Negative emotions related to menstruation were associated with issues of menstrual management, particularly around schooling. In some contexts, these emotions were linked to sociocultural norms around menstrual blood. In a study from Kenya it was reported, “Blood is something so secret that it is not recommended anyone to see” (Mason et al. 2013). A menstrual education programme in Bangladesh included a component on “hot or cold food affecting the menstrual cycle”. The post-test found the proportion of girls reporting that food temperature did not affect menses increased significantly (p = 0.001) (Haque et al. 2014). An intervention in Iran found significant differences in the reporting of emotions (confusing/scared/uncomfortable/good) about menarche between control and intervention groups (Djalalinia et al. 2012).

Menstrual hygiene management

Our review includes studies with a wide range of definitions of “good” or “bad” MHM; in some studies any definition of “good” or “bad” was absent. How questions and response categories were phrased raises questions about the ways in which puberty and menstruation research is framed and understood by researchers. Adolescents reported struggling with menstrual hygiene, including obtaining resources for bathing/washing and absorbents. Kenyan schoolgirls said that competing for scarce resources (e.g. soap, water) could cause familial conflict and shame for girls unable to conceal menstruation (Mason et al. 2013). In India, girls hid used cloths in damp and dusty places (Shah et al. 2013).

Some studies considered sanitary pads to be any commercially branded or cloth pad, or grouped together sanitary pads and cotton in the analyses (Adhikari et al. 2007; Djalalinia et al. 2012). Other studies separated sanitary pads from cloth pads and reported on separate absorbents (Haque et al. 2014; Shah et al. 2013; Um et al. 2010). Most studies considered new cloth or specialty cloth to be hygienic.

Use of sanitary pads was generally low among studies that separated out sanitary pads from other types of absorbents (e.g. cloths), apart from a Nigerian study that reported 93.8% of adolescent schoolgirls used sanitary pads (Um et al. 2010). Whilst most girls preferred and valued sanitary pads, the cost made them unaffordable for many (Mason et al. 2013; Shah et al. 2013; Um et al. 2010). Girls rationed pads or used alternative absorbents (Mason et al. 2013). Evidence from India indicates that girls associated alternative and/or reused absorbents with illness and injury (Shah et al. 2013). One study from Kenya discussed how some girls reported obtaining money for sanitary pads in exchange for sex (Mason et al. 2013).

Studies evaluating interventions relating to MHM included both hardware (Phillips-Howard et al. 2016; Shah et al. 2013) and software interventions (Afsari et al. 2017a; Djalalinia et al. 2012; Haque et al. 2014; Kapadia-Kundu et al. 2014; Kheirollahi et al. 2017; Moodi et al. 2013; Nagaraj and Konapur 2016; Sharma et al. 2015; Su and Lindell 2016). Two linked studies combined hardware and software interventions (Hennegan et al. 2016; Montgomery et al. 2016), and assessed the association with school attendance; there was no association between reusable pads and puberty education and school attendance (Hennegan et al. 2016). Both education and provision of reusable sanitary pads were equally as effective in improving school attendance (Montgomery et al. 2016). A hardware intervention in rural India introduced falalin cloths, a low-cost, easily available red material with good absorption capacity. Girls using falalin cloths reported the fewest adverse quality-of-life issues (e.g. absent from school, skin abrasions), whereas girls using old cloths reported the most. At the study's end, 68% of adolescent girls preferred falalin cloths, whilst 32% of girls preferred sanitary pads (Shah et al. 2013); none preferred old cloths.

Haque et al. (Haque et al. 2014) delivered culturally adapted menstrual education, including menstrual hygiene demonstrations, to schoolgirls. They reported significant (p < 0.05) improvement in use of sanitary pads, the frequency of changing pads/cloths, drying the absorbent outside in sunlight, disposal of the absorbent by burial/burning/binning, and cleaning genitalia (Haque et al. 2014). In Iran, researchers randomly allocated students to one of three groups (control, trained by parents, trained by school) for a training programme. The trained groups bathed more frequently during menstruation than the control group and were more likely to use sanitary pads or cotton as a menstrual absorbent. This community-based educational intervention reported benefiting from including parents and teachers, although the study reports many limitations, including missing data values (Djalalinia et al. 2012). The education program implemented by Sharma et al. (2015) among Indian schoolgirls found a significant (p = 0.01) impact on the frequency of changing sanitary pads, genital cleaning, and reuse of cloths after washing. However, the study failed to include significant details about the study design, intervention, and outcomes.